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Page Foreword ..........................................................................................................................v Acknowledgement..................................................................................................... vii 1. Manifestation of Dengue Infection .............................................................. 1 2. Recognition of Dengue Fever/Dengue Haemorrhagic Fever (DF/DHF) ....................................................................................................2 3. Disease Course..................................................................................................... 4 4. Grading the Severity of Dengue Infection................................................. 5 5. Treatment of DF and DHF .............................................................................. 6 5.1 Febrile Phase................................................................................................. 6 5.2 Afebrile Phase............................................................................................... 7 6. Fluids Required for Intravenous Therapy................................... 16 7. Important Instructions for Treatment of DHF....................................... 19 8. What not to do.................................................................................................. 20 9. Signs of Recovery.............................................................................................. 20 10. Criteria for Discharging Patients ................................................................. 21 11. Reporting.............................................................................................................. 21 12. References (for further information)......................................................... 21 Annexes 1. 2. 3. Blood samples should be drawn from suspected DF/DHF/DSS cases.......................................................................................... 22 Handout for Patients with Dengue Fever ............................................... 24 Information on Personal Protection against Dengue Fever and Dengue Haemorrhagic Fever ................................................. 25

iii

Foreword
In the past 15 years, we have witnessed a dramatic increase in the global incidence of dengue and its severe manifestations such as dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS). The epidemics in endemic countries are occurring more frequently with increasing magnitude. More than 2.5 billion people are at risk of infections in over 200 countries worldwide. There are probably tens of millions of cases of dengue each year, and at least five hundred thousand cases of DHF with a mortality of about five per cent in most countries. The vast majority of cases, nearly 95 per cent, are among children of less than 15 years of age. Clearly this infection, which is already the most widespread mosquito -borne disease in humans, is of major public health importance. The present guidelines on treatment of DF/DHF in small hospitals have been developed by WHO, in consultation with the leading experts in the field of clinical management of DHF. I am sure, these guidelines will be a proper tool for physicians working in small hospitals to conduct appropriate treatment of patients with DF/DHF, and would help in achieving our common target to reduce case fatality rate of DHF to less than one per cent in all endemic countries.

Dr Uton Muchtar Rafei Regional Director

v

Ms Candy Longmire.Acknowledgement The WHO Regional Office for South-East Asia gratefully acknowledges the technical suggestions/comments of Dr Suchitra Nimmannitya. vii . in the finalization of this document. Dr Siripen Kalayanarooj. and secretarial assistance provided by Mr Chander Shekhar Sharma.

1997 (2nd Edition). These guidelines are intended to help the staff working in small hospitals to treat uncomplicated cases of DF/DHF. It is possible to give intravenous fluids a blood transfusion. Standard treatment of DF/DHF has many advantages.000 cases of dengue haemorrhagic fever (DHF) each year which require hospitalization. Fax: 91 11 3318412 and 3318607. It also rationalizes hospitalization. There are common features which will help in categorization of health facilities into small hospitals and referral hospitals. following diarrhoeal diseases and acute respiratory infections. detailed instructions on intensive care are not included. and practical guidelines can be further adapted by Member States. In such cases. Blood haematocrit. World Health House. These simplified.org. Essential nd drugs are available. It is possible that an occasional patient may develo complications. p the guidelines given in this document should be used and other materials for providing intensive care should also be used. A large number of DF/DHF patients first visit small hospitals in their countries. Nepal. Sri Lanka and Thailand. Andjaparidze). please contact the WHO Regional Office for South-East Asia (Attn. comments and suggestions. Deaths due to DHF can be reduced to less than 1% among hospitalized patients by the widespread use of standard treatment. Treatment. Examples of small hospitals in countries of the Region include district hospitals in Bhutan. For additional information.G. if it is not feasible to refer the patient. However. haemoglobin and platelet counts can be done. A small hospital is a health facility where doctors are responsible for treatment of patients and where there are facilities to admit sick individuals. DF/DHF has become a leading cause of hospitalization and death among children in the South-East Asia Region of WHO. Prevention and Control. It is estimated that there are between 50 and 100 million cases of dengue fever (DF) and about 500. In some small hospitals. The present guidelines on treatment of DF/DHF in small hospitals were adapted from the WHO document. basic intensive care can also be provided. and prevents unnecessary blood transfusions. Telephone: 91 11 331 7804 to 7823. India. These guidelines do not address details of prevention of the disease (Staff in small hospitals should refer to specific guidelines on the prevention and control of DF/DHF). Dr Vijay Kumar/Dr A. and township hospitals in Myanmar. Division of Integrated Control of Diseases. and Email address: andjaparidzea@whosea. community health centers and subdistrict hospitals in India. Wherever English is not commonly known in small hospitals. New Delhi – 110 002. the guidelines should be translated into the local language for effective use at country level. reduces the pressure of admissions. Small hospitals which are privately run including nursing homes and other hospitals which admit patients and have the above mentioned facilities should also be encouraged to use these guidelines.Guidelines for Treatment of Dengue Fever/ Dengue Haemorrhagic Fever in Small Hospitals Dengue is the most important emerging tropical viral disease of humans in the world today. thana health centres in Bangladesh. Dengue Haemorrhagic Fever – Diagnosis. health centers (puskesmas) in Indonesia. Small hospitals vary from country to country and within each country. Over the last 10-15 years. ix .

dengue fever (DF).1. Manifestation of Dengue Infection All four dengue virus (Den 1. 3 and 4) infections may be asymptomatic or may lead to undifferentiated fever. 2. Manifestation of dengue virus infections: ASYMPTOMATIC Undifferentiated Fever Without haemorrhage With unusual haemorrhage SYMPTOMATIC Dengue Fever Dengue Haemorrhagic Fever No shock DSS 1 . dengue shock syndrome (DSS). or dengue haemorrhagic fever (DHF) with plasma leakage that may lead to hypovolemic shock.

2 . The test may be negative or mildly positive during the phase of profound shock. ecchymosis or purpura Bleeding from mucosa (mostly epistaxis or bleeding from gums). injection sites or other sites Haematemesis or melena The tourniquet test is performed by inflating a blood pressure cuff to a point mid-way between the systolic and diastolic pressures for five minutes. Dengue Haemorrhagic Fever is a probable case of dengue and haemorrhagic tendency evidenced by one or more of the following: Ø Ø Ø Ø 1 Positive tourniquet test Petechiae. DF is usually mild. A test is considered positive when 10 or more petechiae per 2. the test usually gives a definite positive result (i. DF may be the classic incapacitating disease with severe bone pain and recovery may be associated with prolonged fatigue and depression.Guidelines for Tre atment of Dengue Fever/Dengue Haemorrhagic Fever in Small Hospitals 2. (petechiae and positive In children.5 cm2 (1 inch) are observed. Recognition of Dengue Fever/Dengue Haemorrhagic Fever (DF/DHF) Dengue Fever is an acute febrile illness of 2-7 days duration (sometimes with two peaks) with two or more of the following manifestations: Ø Ø Ø Ø Ø Ø headache retro -orbital pain myalgia/arthralgia rash haemorrhagic manifestation tourniquet test1) and. In some adults.e. >20 petechiae). In DHF. leukopenia.

for reporting of the disease. ascites or hypoproteinaemia). There are difficulties in categorizing the disease. Added serological evidence would categorize them into probable and confirmed cases.mm or less) and Evidence of plasma leakage due to increased capillary permeability manifested by one or more of the following: – – – A >20% rise in haemotocrit for age and sex A >20% drop in haemotocrit following treatment with fluids as compared to baseline Signs of plasma leakage (pleural effusion. hypotension for age. 3 . The above descriptions of DF/DHF/DSS are adequate for guiding doctors to treat the disease. A patient can progress from DHF to DSS. there should be no difficulties in providing treatment. or in referring patients for specialised care. cold and clammy skin and restlessness. It is recommended that blood samples of patients be sent to a laboratory according to the guidelines provided at Annex 1. However. as long as the patient evaluation is done systematically.000/cu. However. cases should be classified as suspected DF/DHF/DSS on the basis of above the criteria. and depending on the stage of the disease when the patient reports. Dengue Shock Syndrome (DSS) All the above criteria of DHF plus signs of circulatory failure manifested by rapid and weak pulse. Serological and virological diagnosis is not possible in most small hospitals.Guidelines for Treatment of Dengue Fever/Dengue Haemorrhagic Fever in Small Hospitals Ø Ø Thrombocytopaenia (platelets 100. a mixed picture can be seen. or in decision making about admission to a hospital. narrow pulse pressure (< or equal to 20 mm Hg).

the case fatality rate can be substantially reduced. The disease course of DF/DHF is summarised below: DHF (Grades) I II III IV DF Febrile Phase (3-7 days) Afebrile Phase (critical stage) * Convalescent Phase RECOVERY * If appropriate treatment is not provided. there is a high risk of death. This is followed by a critical phase which is of about 2-3 days duration. 4 . arrangements for rapid and appropriate treatment should be always available. Since haemorrhage and or shock can occur rapidly. Disease Course DF/DHF has an unpredictable course. and is at risk of developing DHF/DSS which may prove fatal if prompt and appropriate treatment is not provided. By doing this.Guidelines for Tre atment of Dengue Fever/Dengue Haemorrhagic Fever in Small Hospitals 3. the patient is afebrile. During this phase. Most patients have a febrile phase lasting 2 -7 days.

Guidelines for Treatment of Dengue Fever/Dengue Haemorrhagic Fever in Small Hospitals 4. Hct rise >20% * DHF Grade III and IV are also called as Dengue Shock Syndrome (DSS) 5 . Grading the Severity of Dengue Infection To decide about where to treat the patient. no evidence of plasma loss Thrombocytopenia <100.000. may be present. myalgia. The severity of dengue infection is classified into the grades described in Table 1 below. Hct rise >20% Above signs plus circulatory failure (weak pulse. retro -orbital pain. Table 1 DF/DHF Grade* Symptoms Laboratory DF Fever with two or more of the following signs: headache. hypotension.000. Hct rise >20% DHF III DHF IV Thrombocytopenia <100. it is important to classify the severity of dengue infection. Hct rise >20% DHF DHF II Above signs plus Thrombocytopenia spontaneous bleeding <100.000.000. Thrombocytopenia. restlessness) Profound shock with undetectable blood pressure and pulse Thrombocytopenia <100. arthralgia I Above signs plus positive tourniquet test Leukopenia occasionally.

Food should be given according to appetite. Do not give antibiotics as these do not help. oral rehydration solution which is commonly used in the treatment of diarrhoeal diseases and/or fresh juices are preferable(50ml/kg bodyweight fluids should be given during the first 4-6 hr)s. In children. oral fluid intake of 2. i. In adults. Paracetamol (not more than 4 times in 24 hours) according to age for fever above 39 0C. Aspirin can cause gastritis and/or bleeding. Their treatments during the febrile phase are the same. Age Dose (tablet 250 mg) Mg/Dose < 1 year 1-4 years 5 years and above ¼ tablet ½ tablet 1 tablet 60 60-120 240 Ø Do not give Aspirin or Brufen.5-4. symptomatic and supportive: Ø Ø Rest.e. 6 . the child should be given maintenance fluids orally at the rate of 80-100 ml/kg bodyweight in the next 24 hrs . Ø Ø Ø 2 In Children. Reye’s syndrome (encephalopathy) may be a serious complication. with signs of some dehydration. After correction of dehydration. Oral rehydration therapy2 is recommended for patients with moderate dehydration caused by vomiting and high temperature. Children who are breastfed should continue to be breasfed in addition to ORS administration.1 Febrile Phase In the early febrile phase.Guidelines for Tre atment of Dengue Fever/Dengue Haemorrhagic Fever in Small Hospitals 5.0 litres should be given per day. it is not possible to distinguish DF from DHF. Treatment of DF and DHF 5.

the patient has the same symptoms as during the febrile phase. sweating.Guidelines for Treatment of Dengue Fever/Dengue Haemorrhagic Fever in Small Hospitals All dengue patients must be carefully observed for complications for at least 2 days after recovery from fever. 5. The clinical signs plus thrombocytopenia and haemoconcentration or rise in haematocrit are sufficient to establish a clinical diagnosis of DHF. This is because life threatening complications often occur during this phase. for rashes on the skin.2 (1) Afebrile Phase Dengue Fever Constitutional symptoms in patients with DF after the fall of fever are as during the febrile stage. bleeding from nose or gums. blue spots on the skin or tarry stools. If any of these signs are observed. (2) Dengue Haemorrhagic Fever (DHF) Grades I and II As in DF. The only difference between th e DF and DHF Grade I is the presence of thrombocytopenia and rise in haematocrit (>20%). Detailed information which should be provided to all patients and households by the doctor is given in Annex 2. During this phase. the patients should be brought to the hospital without delay. bleeding into the skin or from the nose or gums. passage of black stools. the patient should be taken to the hospital. and cold skin are danger signs. Patients and households should be informed that severe abdominal pain. If any of these signs is noticed. during the afebrile phase of DHF Grades I and II. the patients should be observed for at least 2-3 days after the fall in temperature. Treatment should be carried out as indicated in Chart 1. Intravenous fluid therapy may need to 7 . Patients with DHF Grade I do not usually require intravenous fluid therapy and ORT is sufficient. Most patients will recover without complication. The patient who does not have any evidence of complications and who has been afebrile for 2-3 days does not need further observation.

8 . – Normal diet * Patients and household members should be informed by the doctor that abdominal pain. Paracetamol (250mg): <1yr-1/4 tablet. DF/DHF Management Charts Dengue Fever Febrile phase Duration 2-7 days – – – – – – – – – – – – Afebrile phase (critical stage) Duration – 2-3 days after febrile stage Manifestation Temp 39-40ºC Headache Retro-orbital pain Muscle pain Joint/bone pain Flushed face Rash Skin haemorrhage. 5 yrs and above – one tablet. bleeding. gums Positive tourniquet test Liver often enlarged Leucopenia Platelet/haematocrit normal Management – At home ∗ – Bed rest – Keep the body temperature below 390 – Paracetamol-Yes** – Aspirin-No – Brufen-No – Oral fluids and electrolyte therapy – Follow-up for any change in platelet/haematocrit Manifestation – Same as during febrile phase – Improvement in general condition – Platelet/haematocrit normal – Appetite rapidly regained Management – Bed rest – Check platelets/haematocrit – Oral fluids and electrolyte therapy Convalescence Phase Duration – 7-10 days after critical stage Manifestation – Further improvement in general condition and return of appetite – Bradycardia – Confluent petechial rash with white centre/ itching – Weakness for 1 or 2 weeks Management – No special advice. bleeding from nose. sweating. the patient should be taken to the hospital immediately. and if any of these signs is noticed. 1-4 years – ½ tablet. and cold skin are danger signs.Guidelines for Tre atment of Dengue Fever/Dengue Haemorrhagic Fever in Small Hospitals Chart 1. passing of black stools. ** Paracetamol should be administered not more than 4 times in a 24-hour period. – No restrictions.

9 . This is an important life saving measure. are abdominal pain. Intravenous fluid therapy before leakage is not recommended. isotonic saline solution) can reduce the severity of the disease and prevent shock. or refusing to accept oral fluids. haematocrit and platelet count must be carried out to assess the patient’s condition. the treatment should be reviewed and revised. Graphical presentation of the treatment of DHF is given in Figure 1. and continued bleeding from injection sites. Patients should be monitored on an hourly basis by medical personnel. Treatment should be performed as indicated in Chart 2. in addition to those observed during the DHF Grade I phase. Patients with DHF Grade I who live far away from the hospital or those who are not likely to be able to follow the medical advice should be kept in the hospital for observation. black tarry stools. bleeding from the gums. During the afebrile phase of DHF Grade II. Early volume replacement of lost plasma with Cystalloid 3 solution (e. 3 Crystalloid Solutions : (a) 5% dextrose in isotonic normal saline solution (5% D/NSS) (b) 5% dextrose in half-strength normal saline solution (5% D/1/2/NSS) (c) 5% dextrose in lactated Ringer’s solution (5% D/RL) (d) 5% dextrose in acetated Ringer’s solution (5% D/RA).g.Guidelines for Treatment of Dengue Fever/Dengue Haemorrhagic Fever in Small Hospitals be administered only when the patient is vomiting persistently or severely. Immediately after hospitalization. epistaxis.g. the complications usually seen. A rise in haematocrit of 20% or more (e.000/mm3 or less than 1-2 platelets/oil field (average of 10 oil field counts) usually precedes a rise in haematocrit. increase from 35% to 42%) reflects a significant plasma loss and indicates the need for intravenous fluid therapy. intravenous fluid therapy may be given for a period of 12-24 hours in a small hospital or short stay unit (OPD) of a large hospital. Based on periodic haematocrit/platelet count determinations and vital signs. A reduction in the platelet count to ≤100. In mild to moderate cases of DHF Grade II.

continue IV therapy at 3ml/kg/hr (612 hours) and then discontinue IV therapy – In case of no improvement 5 increase IV therapy to 10 ml/kg/hr (for 1 hr). – Generally. urine output rises No Improvement: Haematocrit or pulse rate rises. urine output falls 10 . – Thrombocytopenia and rise in haematocrit level (more than 20%) – OPD or hospital – ORS – Check platelets/haematocrit. DHF Grades I and II do not give complications Management Convalescence Phase Manifestation Duration 2-3 days after critical stage – Further improvement in general condition and return of appetite – Bradycardia – Confluent petechial rash with white centre/ itching – Asthenia and depression (sometimes for a few weeks. If haematocrit is more than 20%: – Initiate IV therapy (5% D/NSS) 6 ml/kg/hr (for 3 hours) – Check haematocrit/vital signs/urine output after 3 hours. Dengue Haemorrhagic Fever (Grades I and II) (The manifestations and management of DF and DHF during the febrile phase are the same) Afebrile Phase (critical stage) Manifes tation Management Duration 2-3 days – Same as during febrile phase. and in case of improvement4 – Reduce IV therapy to 3ml/kg/hr (for 3 hours) – In case of further improvement. reduce the volume of IV from 10ml/kg/hr to 6ml/kg/hr and further to 3ml/kg/hr accordingly. pulse rate and blood pressure stable. pulse pressure below 20 mm Hg.Guidelines for Tre atment of Dengue Fever/Dengue Haemorrhagic Fever in Small Hospitals Chart 2. In case of improvement now. common in adults) – Normal diet – No need for any medication 4 5 Improvement: Haematocrit falls.

Haematocrit Falls Blood transfusion 10 ml/kg/hr duration 1 hr. signs of shock 11 .7kPa). 6 to 3m l/kg/hr Discontinue after 24-48 hrs Improvement: Haematocrit falls. Thrombocytopenia. pulse rate and blood pressure stable. discontinue after 24-48 hrs No Improvement Unstable Vital Signs Haematocrit Rises IV Colloid (Dextran (40) 10ml/kg/hr duration 1 hr. urine output rises No improvement: Haematocrit or pulse rate rises. Haematocrit rise. Pulse pressure is low Initiate IV Therapy 6m l/kg/hr Crystalloid solution for 1-2 hrs Improvement Reduce IV 3ml/kg/h Crystalloid duration 6-12 hrs No Improvement Increase IV 10 ml/kg/h crystalloid duration 2 hrs. urine output falls Unstable vital signs:Urine output falls. Improvement IV therapy by crystalloid Successively reduce the flow from 10 to 6.Guidelines for Treatment of Dengue Fever/Dengue Haemorrhagic Fever in Small Hospitals Figure 1. pulse pressure falls below 20mmHg (2. Further Improvement Discontinue IV after 24 hrs Improvement Reduce IV to 6ml/kg/h crystalloid with further reduction to 3 ml/kg/h. Volume Replacement Flow Chart for Patients with DHF Grades I and II Haemorrhagic (bleeding) tendencies.

It is thus recommended to give fresh whole blood in small volumes of 10ml/kg bodyweight at one time. The graphical presentation of treatment of DHF Grades III and IV is given in Figure 2. platelet count and vital signs should be examined to assess the patient’s condition and intravenous fluid therapy should be started. If the patient has already received about 1. The patient requires regular and sustained monitoring. the haematocrit continues to decline. Immedia tely after hospitalization. In case of continued or profound shock when pulse and blood pressure are undetectable. The detailed treatment for patients with DHF Grades III and IV is given in Chart 3. narrowing of the pulse pressure and hypotension. restlessness. intravenous fluid should be changed to colloidal solution preferably Dextran. after initial fluid replacement and resuscitation with plasma or plasma expanders. the haematocrit. It may be difficult to recognize and estimate the degree of internal blood loss in the presence of haemoconcentration. characterised by high diastolic pressure relative to systolic pressure (for example 90/80) and the presence of cold clammy skin and restlessness.Guidelines for Tre atment of Dengue Fever/Dengue Haemorrhagic Fever in Small Hospitals (3) DHF Grades III and IV Common signs of complications observed during the afebrile phase of DHF Grade III include circulatory failure manifested by rapid and weak pulse. internal bleeding should be suspected. The patient. cold and clammy skin. abnormal haemostasis and plasma leakage. in the case of persistent shock when. fresh whole i blood transfusion 10ml/kg/dose should be given. in the early stage of shock. the haematocrit should be repeated and: (a) if the haematocrit is increasing. 12 . Oxygen should be given to all patients in shock. However. These complications occur because of thrombocytopenia. vital signs are unstable. or (b) f haematocrit is decreasing. or also from substantial blood loss. the patient should be given colloidal fluid following the initial fluid bolus. rapid and weak pulse. has acute abdominal pain.000 ml of intravenous fluids and the vital signs are still not stable. Blood grouping and matching should be done for all patients in shock as a routine precaution. The patient should be administered intravenous fluid therapy immediately. During the afebrile phase of DHF Grade IV.

and from 6 to 3 ml/kg/h which can be maintained up to 24 to 48 hours – If patient has already received one hour treatment of 20 ml/kg/hr of IV fluids and vital signs are not stable. urine output every hour – If patient improves. vital signs. Profound shock with undetectable pulse and blood pressure 6 Oxygen is obligatory until shock has been overcome. colloidal fluids (Dextran or Plasma) should be given at 1020 ml/kg/hr. narrowing of pulse pressure (20 mmHg or less) or hypotension with the presence of cold clammy skin and restlessness – Capillary relief time more than two seconds Management – Check haematocrits/platelet – Initiate IV therapy (5% D/NSS) 10 ml/kg/h – Check haematocrit. 13 . Pulse. change IV fluid to colloidal solution preferably Dextran or Plasma at 10 ml/kg/h every hr. IV fluids should be reduced every hour from 10 to 6.Guidelines for Treatment of Dengue Fever/Dengue Haemorrhagic Fever in Small Hospitals Chart 3. 10 ml/kg/h and continue fluid therapy at 10 ml/kg/h and reducing it stepwise bring down the volume to 3 ml/kg/h and maintain it up to 24-48 hours – Initiate IV therapy (5% D/NSS) 20 ml/kg as a bolus one or two times – Oxygen therapy should be given to all patients6 – In case of continued shock. – If haematocrit is decreasing from initial value. Afebrile phase Duration two days after febrile stage Manifestation In addition to the manifestations of DHF Grade II: – Circulatory failure manifested by rapid and weak pulse. and temp should be recorded every 15-30 minutes. check haematocrit again and – If haematocrit is increasing. Dengu e Haemorrhagic Fever (Grades III and IV) The patient in this category should be admitted to a hospital where trained personnel can manage shock and blood transfusion facilities are available (referral hospital). give fresh whole blood transfusion. blood pressure.

give fresh whole blood 20 ml/kg as a bolus – Give platelet rich plasma transfusion exceptionally when platelet counts are below 5.000–10. continue fluid therapy at 10 ml/kg/h and reduce it stepwise to bring it down to 3 ml/kg/h and maintain it for 24-48 hrs Con. some symptoms of respiratory distress (pleural effusion or ascites) – 2-3 days after critical stage.000/ mm3 . normal blood pressure – Improved general condition/return of appetite – Good urine output – Stable haematocrit – Platelet count >50. – After blood transfusion. give fresh whole blood 10 ml/kg as a bolus – Vital signs should be monitored every 30-60 minutes – In case of severe bleeding.000 per mm 3 – Patient could be discharged from hospital 2-3 days after critical stage – Bradycardia/arrhythmia – Asthenia and depression (few weeks) in adults Management – Rest for 1-2 days – Normal diet – No need for medication 14 . strong pulse.Guidelines for Tre atment of Dengue Fever/Dengue Haemorrhagic Fever in Small Hospitals Afebrile phase Manifestation Profound shock with undetectable pulse and blood pressure Management – If shock still persists and the haematocrit level continues declining. Phase Duration 2-3 days after recovery from critical/shock stage Manifestation – 6-12 hours after critical/shock stage.

10 to 6. successively reducing the flow from 10 to 6. and 6 to 3ml/kg/hr Further Improvement Discontinue intravenous therapy after 24-48 hrs Haematocrit Rises IV Colloid (Dextran 40) or plasma 10ml/kg/hr as intravenous bolus (repeat if necessary) Oxygen Haematocrit Falls Blood transfusion (10 ml/kg/hr) if haematocrit is still >35% Improvement IV therapy by crystalloid. hyperosmolar or Ringer’s lactate solution should notbe used 15 .Guidelines for Treatment of Dengue Fever/Dengue Haemorrhagic Fever in Small Hospitals Figure 2. rapid volume replacement*: Initiate IV therapy 10-20ml/kg/h Cystalloid solution for 1 hr Improvement No Improvement IV Therapy by crystalloid successively reducing from 20 to10. Volume Replacement Flow Chart for patient with DHF Grades III and IV UNSTABLE VITAL SIGNS Urine Output Falls Signs Of Shock Immediate. 6 to 3ml/kg/hr Discontinue after 24-48 hrs ___________________ * In cases of acidosis.

The volume of fluid replacement should be just sufficient to maintain effective circulation during the period of plasma leakage.Guidelines for Tre atment of Dengue Fever/Dengue Haemorrhagic Fever in Small Hospitals 6. The regimen of the flow of fluid and the time of infusion are dependent on the severity of DHF. The schedule given below is recommended as a guideline. It is calculated for moderate dehydration of about 6% deficit (plus maintenance). Fluids Required for Intravenous Therapy Fluids Recommended Crystalloid: (a) 5% dextrose in isotonic normal saline solution (5% D/NSS) (b) 5% dextrose in half-strength normal saline solution (5% D/1/2/NSS) (c) 5% dextrose in lactated Ringer’s solution (5% D/RL) (d) 5% dextrose in acetated Ringer’s solution (5% D/RA) Colloidal: Dextran 40. or even more frequently in the case of shock. This can be dangerous. the rate of intravenous fluid should be adjusted throughout the 24 to 48 hour period of plasma leakage by periodic haematocrit determinations and frequent assessment of vital signs. The required regimen of fluid should be calculated on the basis of bodyweight and charted on a 1-3 hourly basis. ascites. Plasma: In order to ensure adequate fluid replacement and avoid over-fluid infusion. Excessive fluid replacement and continuation for a longer period after cessation of leakage will cause respiratory distress from massive pleural effusion. 16 . and pulmonary congestion/ oedema.

Guidelines for Treatment of Dengue Fever/Dengue Haemorrhagic Fever in Small Hospitals Ml/lb Bodyweight/day 100 75 60 40 Weight on admission Lbs <15 16-25 26-40 >40 Kgs <7 7-11 12-18 >18 Ml/kg Body weight/day 220 165 130 90 In older children who weigh more than 40 kgs. 10ml/kg/hr. based on bodyweight and rate of flow of fluid volume for the four regimen are given in Table 2. the maintenance is: 1500 + (20x20) = 1900 ml. 6ml/kg/hr. the calculation of fluid requirements. The maintenance fluid should be calculated as follows: Body weight (kgs) <10 10-20 >20 Maintenance volume (ml) administered over 24 hrs 100/Kg 1000+50 for each kg in excess of 10 1500+20 for each kg in excess of 20 For a child weighing 40 kgs. and 20ml/kg/hr. For ready reference.: 3ml/kg/hr. four regimens of flow of fluid are suggested. 17 . This means that the child requires 3800 ml IV fluid during 24 hours. For intravenous fluid therapy of patients with DHF. the volume needed for 24 hours should be calculated as twice that required for maintenance (using the Holliday and Segar formula).

and 4 – 20ml/kg/hr Ø Ø The fluid volumes mentioned are approximations. REMEMBER that ONE ML is equal to 20 DROPS. Ø Ø 18 . In case of MACRO system. and from R-2 to R-1 in a stepwise manner. from R-3 to R2. one ml is equal to 15 drops. and order more as and when required. Do not jump from R-2 to R-4 since this can overload the patient with fluids. Similarly. (if needed adjust fluid speed in drops according to equipment used) It is advised to procure only a bottle of 500 ml initially. 2 – 6ml/kg/hr. The frequency of -3 monitoring should be determined on the basis of the condition of the patient. Requirement of fluid based on bodyweight Bodyweight (in kgs) 10 15 20 25 30 35 40 45 50 55 60 Volume of fluid to be given in 24 hrs 1500 2000 2500 2800 3200 3500 3800 4000 4200 4400 4600 Rate of fluid (ml/hour) R*1 30 45 60 75 90 105 120 135 150 165 180 R*2 60 60 90 120 150 180 210 240 270 300 360 R*3 100 150 200 250 300 350 400 450 500 550 600 R*4 200 300 400 500 600 700 800 900 1000 1100 1200 * Regimen 1 – 3ml/kg/hr.Guidelines for Tre atment of Dengue Fever/Dengue Haemorrhagic Fever in Small Hospitals Table 2. The decision about the sp eed of IV fluid should be reviewed every 1 hours. 3 – 10ml/kg/hr. Normally change should not be drastic. reduce the volume of fluid from R-4 to R-3.

As soon as improvement occurs replace with crystalloid. Then give crystalloid at 10 ml/kg/hr for a short time (30-60 minutes) and later reduce the speed. then to 6 ml. Timely intravenous therapy – isotonic crystalloid solution – can prevent shock and/or lessen its severity. Important Instructions for Treatment of DHF Ø Ø Cases of DHF should be observed every hour.167 mol/litre of sodium bicarbonate (threequarters of crystalloid solution plus glucose plus one -quarter sodium bicarbonate) 19 . and finally to 3 ml/kg. replace crystalloid solution with colloid solution such as Dextran or plasma. use sodium bicarbonate7. drop in plaelets and rise in haematocrits are essential for early diagnosis of DHF. 7 In the case of acidosis. Serial platelet and haematocrit determinations. give oxygen. one-third of the total fluids should consist of 0. If haematocrit falls. In case of shock. In case of severe bleeding. reduce the speed from 20 ml to 10 ml. If the patient’s condition becomes worse despite giving 20ml/kg/hr for one hour. the physician is advised to consult other appropriate references on their treatment. give fresh blood transfusion about 20 ml/kg for two hours. For correction of acidosis (sign: deep breathing). If improvement occurs. Ø Ø Ø Ø Ø Ø Ø For more details on management of DFH/DSS cases. give blood transfusion 10 ml/kg and then give crystalloid IV fluids at the rate of 10ml/kg/hr. A list of references is provided in Section 12.Guidelines for Treatment of Dengue Fever/Dengue Haemorrhagic Fever in Small Hospitals 7.

Do not use antibiotics Do not change the speed of fluid rapidly. i. Avoid giving steroids. What not to do Ø Ø Ø Ø Ø Ø Ø Do not give Aspirin or Brufen for treatment of fever.Guidelines for Tre atment of Dengue Fever/Dengue Haemorrhagic Fever in Small Hospitals 8. avoid rapidly increasing or rapidly slowing the speed of fluids. Avoid giving intravenous therapy before there is evidence of haemorrhage and bleeding. They do not show any benefit. Avoid giving blood transfusion unless indicated. Insertion of nasogastric tube to determine concealed bleeding or to stop bleeding (by cold lavage) is not recommended since it is hazardous. reduction in haematocrit or severe bleeding. blood pressure and breathing rate Normal temperature No evidence of external or internal bleeding Return of appetite No vomiting Good urinary output Stable haematocrit Convalescent confluent petechiae rash 20 . 9.e. Signs of Recovery Ø Ø Ø Ø Ø Ø Ø Ø Stable pulse.

References (for further information) (1) Suchitra Nimmannitya. WHO/SEARO.000/mm3 11. in “Dengue and Dengue Haemorrhagic Fever” edited by D. 21 . Published by CAB International. Dengue Haemorrhagic Fever: diagnosis and management. Geneva. treatment. pp 133-145. WHO/SEARO.J. 1997. 2nd Edition. WHO/SEARO. 22 – Monograph on Dengue/DHF – pp 48-54. New Delhi (3) Suchitra Nimmannitya. New Delhi. probable and confirmed cases of DF/DHF should be reported to the District Health Officer. all suspected. 1998 (in print). 1997. WHO. Gubler and G. New Delhi (2) Suchitra Nimmannitya.Guidelines for Treatment of Dengue Fever/Dengue Haemorrhagic Fever in Small Hospitals 10. “Management of DF/DHF” in WHO Regional Publication No. 12. Reporting Based on case-definitions. (5) “Regional Guidelines for Prevention and Control of Dengue/DHF”. (4) “Dengue Haemorrhagic Fever – diagnosis. Criteria for Discharging Patients Ø Ø Ø Ø Ø Ø Ø Absence of fever for at least 24 hours without the use of anti-fever therapy Return of appetite Visible clinical improvement Good urine output Minimum of three days after recovery from shock No respiratory distress from pleural effusion and no ascites Platelet count of more than 50. Kuno. “Clinical Manifestations of DF/DHF” in WHO Regional Publication No. 22 – Monograph on Dengue/ DHF– pp 55-61. prevention and control”.

Guidelines for Tre atment of Dengue Fever/Dengue Haemorrhagic Fever in Small Hospitals Annex 1 Blood samples should be drawn from suspected DF/DHF/DSS cases (1) In the acute stage – 0-5 days after onset (serum specimen S1).0 ml. Whatman No. Place the dried strips in plastic bags and staple them to the laboratory examination request form (sample below). If refrigeration is not possible for keeping blood samples. All collected samples should be adequately labelled with the name of the patient. Store without refrigeration. Shortly before discharge from the hospital – 6-10 days after onset (serum specimen S2).5-1. Allow the filter paper to dry in a place that is protected from direct sunlight and insects. volume 0. 14-21 days after the onset of disease (serum specimen S3) (2) (3) The serum should be separated from the red blood cells and stored frozen before examination. their identification number and date of collection. and If possible.3 filter paper discs 12. Collect the blood on the filter paper and fully saturate it through to the reverse side.7mm (1/2 inch) in diameter may be used. 22 .

Fever:_____________0C Duration:_________________Days 2. rate and quantity of fluids administered should be kept. 23 . Record urine output. _______________ Name of Patient:____________________ Age:___________Sex: _____________ Date of Admission:__________________ Suspected Diagnosis Date of Onset:________________ __________________________________________________ Clinical Findings: 1. Tourniquet Test:___________________________________________________ 4.no. A fluid balance sheet. Petechiae____________Epistaxis_____________Melaena_________________ Other Bleeding:___________________________________________________ 3.Guidelines for Treatment of Dengue Fever/Dengue Haemorrhagic Fever in Small Hospitals Laboratory Investigation Form for Dengue Infection (Using Filter Paper Discs) Hospital:_________________________________ Regn. recording type. Shock:___________________________________________________________ Specimen Acute (S1) Early Convalescent (S2) (before discharge from hospital) Late Convalescent (S3) Date of Collection ________________ ________________ ________________ Result of Serology ________________ ________________ ________________ Laboratory Diagnosis:______________________________________________ Haematocrit every two hours during the first six hours and later every four hours until stable.

Immediately consult your physician. “What should you do?” Keep body temperature below 39 oC. excessive thirst (dry mouth). vomiting with blood. pale. abdominal pain. cold or clammy skin. sleepiness.Guidelines for Tre atment of Dengue Fever/Dengue Haemorrhagic Fever in Small Hospitals Annex 2 Handout for Patients with Dengue Fever (Important information to be given to the parents or family members of outpatients with suspected dengue fever) Your child or family member probably has dengue fever. The complications associated with dengue fever usually appear between the third and fifth day of illness. Immediately consult your physician if any of the following manifestations appear: Red spots or points on the skin. or difficulty in breathing. constant crying. The patient should rest. Do not wait. black stools. 24 . it is important for you to carefully watch your child or relative for the next few days. f frequent vomiting. Give the patient paracetamol (not more than four times in 24 hours) as per the dose prescribed below: Age < 1 year 1-4 years 5 and above Dose (tablet 250 mg) ¼ tablet ½ tablet 1 tablet Mg/dose 60 60-120 240 Do not give the patient Aspirin or Brufen or Ibubrufen Give large amounts of fluids (water. It is crucial to quickly treat anyone with these complications. You should therefore watch the patient for two days after the fever disappears. bleeding rom the nose or gums. milk and juices) along with the patient’s normal diet. soups. Since this disease can rapidly become very serious and lead to a medical emergency.

it causes the loss of lives. It is most serious in children. Dengue haemorrhagic fever (DHF) is a more severe form. It occurs in two forms: (a) Dengue fever (DF) (b) Dengue haemorrhagic fever (DHF) Dengue fever is marked by an onset of sudden high fever. pain behind the eyes. The patient feels a lot of discomfort and is very weak after the illness. Dengue spreads rapidly and may affect large numbers of people during an epidemic. The high fever continues for 5 days (103-105°F or 39–40°C). severe headache. This can lead to death. and pain in the muscles and joints. Symptoms of bleeding usually occur after 2-3 days of fever.Guidelines for Treatment of Dengue Fever/Dengue Haemorrhagic Fever in Small Hospitals Annex 3 Information on Personal Protection against Dengue Fever and Dengue Haemorrhagic Fever What is dengue infection? Dengue is an acute flu-like fever caused by a virus. in which bleeding and sometimes shock occurs. Recognition of Dengue Fever (1) Sudden onset of high fever (2) Severe headache (mostly in the forehead) (3) Pain behind the eyes which worsens with eye movement (4) Body aches and joint pains (5) Nausea or vomiting 25 . It comes -6 down on the third or the fourth day but rises again. resulting in reduced work productivity. More importantly.

bleeding on the skin or from the nose or gums. Aspirin and Brufen should be avoided in dengue fever. plus any one or a combination of the following: (1) Severe and continuous pain in the abdomen (2) Bleeding from the nose. as they are known to increase the bleeding t ndency and may lead to e serious complications. Severe abdominal pain (black stools). and cold skin. Give the patient fluids to drink while transferring him/her to the hospital. Basic facts on Dengue (1) How does dengue spread? Dengue is spread through the bite of an infected Aedes aegypti mosquito. people must protect themselves from all mosquito bites. The mosquito gets the virus by biting an infected person. Proper and early treatment can relieve the symptoms and prevent complications and death. etc. mouth and gums or skin bruising (3) Frequent vomiting with or without blood (4) Black stools like coal tar (5) Excessive thirst (dry mouth) (6) Pale. Treatment Patient(s) suspected of having DF or DHF must be examined by a doctor. are danger signs. If any one of them is noticed. Paracetamol can be given on medical advice.Guidelines for Tre atment of Dengue Fever/Dengue Haemorrhagic Fever in Small Hospitals Recognition of Dengue Haemorrhagic Fever and Shock Symptoms similar to dengue fever. specific diagnosis is not required for treatment of patients with DF/DHF. The first symptoms of the disease occur about 5-7 days after the infected bite. There is no way to tell if a mosquito is carrying the dengue virus. 26 . cold skin Diagnosis Confirmation of DF and DHF can be done by specific laboratory tests. sweating. take the patient to a hospital immediately. However. Therefore.

water coolers. The favoured breeding places are: barrels. Mosquito nets and mosquito coils will effectively prevent more mosquitoes from biting sick people and help stop the spread of dengue.Protect Yourself From the Bite (b) Wear full-sleeve clothes and long dresses to cover the limbs. flower vases. pots. These eggs become adults in about 10 days.Guidelines for Treatment of Dengue Fever/Dengue Haemorrhagic Fever in Small Hospitals (2) Where does this mosquito live? This mosquito rests indoors. It is important to take control measures to eliminate the mosquitoes and their breeding places. tyres. Efforts should be intensified before the transmission season (during and after the rainy season) and during epidemics. drums. plant saucers. tanks. to repel or kill mosquitoes. (c) Use repellents – care should be taken in using repellents on young children and elders. The female mosquito lays her eggs in water containers in and around homes. Mosquitoes become infected when they bite people who are sick with dengue. discarded bottles/tins. water collection systems. exposed. etc. (e) Use mosquito nets to protect babies. (d) Use mosquito coils and electric vapour mats during the daytime to prevent dengue. Prevention of Dengue All control efforts should be directed against the mosquitoes. jars. old people and others who may rest during the day. buckets. Curtains (cloth or bamboo) can also be treated with insecticide and hung at windows or doorways. it rests where it is cool and shaded. 27 . schools and other areas in towns or villages. and a lot more places where rainwater collects or is stored. (3) Where does the mosquito breed? Dengue mosquitoes breed in stored. (1) Prevent mosquito bites: (a) Dengue Mosquitoes Bite During the Daytime . The effectiveness of such nets can be improved by treating them with permethrin (pyrethroid insecticide). Outside. in closets and other dark places. (f) Break the cycle of mosquito-human-mosquito infection.

plastic bags.Guidelines for Tre atment of Dengue Fever/Dengue Haemorrhagic Fever in Small Hospitals (2) Prevent the multiplication of mosquitoes: Mosquitoes which spread dengue live and breed in stagnant water in and around houses. (c) All stored water containers should be kept covered at all times. tyres. buckets. 28 . drums. tins.g. plant saucers. (b) Remove all objects containing water (e. etc. tanks. barrels. (a) Drain out the water from desert/window air coolers (when not in use).g. etc.) from the house. e. bottles. (d) Collect and destroy discarded containers in which water collects. etc.